R432-31-4. Facility Policies and Procedures

(1) A licensee shall establish and implement policies and procedures that comply with Section 26B-2-802. (2) A licensee shall ensure policies and procedures address the licensee's responsibility to: (a) determine upon admission whether each individual has an OLST; (b) ensure an OLST is done in accordance with Section 26B-2-802; (c) identify circumstances when an individual with an OLST is offered the opportunity to change the order; (d) identify circumstances when the facility would not follow an OLST; (e) identify any individual who may be offered the opportunity to complete an OLST, including an individual who has: (i) a serious illness and is likely to face a life-threatening health crisis; (ii) declining cognitive abilities and lacks a surrogate or guardian to make decisions for them; or (iii) specific preferences for end-of-life treatments; (f) make a referral to the primary health care provider to create, replace, or change an OLST, if the licensee's services do not include the supervision of a physician, APRN, or physician assistant; (g) maintain the OLST in the individual's medical record; (h) only permit a qualified provider to assist with the completion of an OLST; and (i) outline that the licensee is not required to offer each individual the opportunity to complete an OLST.